Medicaid Program – Oversight of Health Homes
Learn how the AI-generated research projects were createdOverall Conclusion
DOH did not adequately oversee Medicaid Health Homes to ensure appropriate care and payments, including delays in redesignation reviews, noncompliance with policies, and lack of baseline measurements, with $19.7 million in payments lacking proper MAPP-based support; the agency has since implemented improvements to redesignation processes and related controls.
Source Document
Audit Scope
January 2019 through June 2023, with analysis of selected performance measures through March 2024 and review of the redesignation process through October 2024.
Key Findings Summary
DOH did not adequately oversee Medicaid Health Homes to ensure appropriate care and payments, including not completing redesignation reviews for all Health Homes within the required time frames and inconsistent monitoring prior to August 2023 when improvements were implemented.
Health Homes frequently did not comply with Medicaid policies and procedures, such as updating members’ care plans when needed.
Performance measure calculations did not include baseline measurements, hindering evaluation of progress and program effectiveness.
View the Findings tab to see all 4 findings
AI-Assisted
AI Scope Summary
The audit assessed DOH's oversight of Medicaid Health Homes during 2019–2023, focusing on redesignation timeliness, compliance with program policies, and the adequacy of performance measures, including the absence of baseline data; it concluded that oversight was insufficient but noted substantial enhancements to the redesignation process and related controls beginning in 2023, guiding future audits to emphasize timely redesignation, robust baseline analyses, and solid attestation reviews.
AI-Generated Insight
The audit highlights systemic gaps in oversight of Health Homes and the MAPP-based attestation process, suggesting that stronger data-integrity controls and baseline-performance data could improve program evaluation and reduce improper payments.
Audit Objectives
To determine whether the Department of Health (DOH) has provided adequate oversight of Medicaid Health Homes to ensure that appropriate care was provided and that appropriate payments were made.
Audit Findings (4)
DOH did not adequately oversee Medicaid Health Homes to ensure appropriate care and payments, including not completing redesignation reviews for all Health Homes within the required time frames and inconsistent monitoring prior to August 2023 when improvements were implemented.
Health Homes frequently did not comply with Medicaid policies and procedures, such as updating members’ care plans when needed.
Performance measure calculations did not include baseline measurements, hindering evaluation of progress and program effectiveness.
From January 2019 through June 2023, auditors identified $19.7 million in payments across 67,026 claims that lacked proper support in the MAPP System.
Recommendations (7)
Ensure redesignation reviews are conducted timely in accordance with the redesignation policy.
Formally evaluate whether the redesignation process should be improved to ensure that Health Homes (via the plan of care and other actions) are addressing the underlying risk factors members were identified to have upon enrollment in the Health Home program.
Ensure that Health Homes submit Enhanced Oversight Plans timely, when required, and with adequate detail.
Formally evaluate whether to include baseline data calculations (such as Health Home member circumstances before enrollment) in the Health Home performance measures to: More accurately score Domain 2 of Health Home redesignation reviews, and Effectively measure the overall performance of the Program.
Review the $19.7 million in payments that lacked proper support in the MAPP System attestations, and make recoveries, as appropriate.
Ensure that Health Home claims are properly supported in the MAPP System and make recoveries on improper payments, as appropriate.
Ensure the MCO identified in this report takes corrective actions to prevent erroneously paying voided Health Home claims due to retroactive rate changes.